The Sector Linkage Model for Improved Patient Flow. Dr. Peter Nord
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1 The Sector Linkage Model for Improved Patient Flow Dr. Peter Nord
2 Based on Premise that Better Quality Outcomes Result from Better Flow
3 Healing Trajectories Current & Future Health Status Measures (FIM) Acute Event Acute Admit to Care Tx Acute Care Admit to Rehab Patient Stable ALC for Rehab Transition to Outpatient Care Duration of Inpt. care Self Management Deterioration while ALC in Acute Care Remove ALC/Wait Time in Acute care (see people sooner) Caregiver Support Needs-Based Service Bundles Navigation Support Admit to Rehab Outpatient Care Ends Transition to Outpatient Care Time to Outpatient Care Reduced Duration of Outpt. Care Fitness/ Wellness Re-admission to Acute Care? Future state Current state Above this line = Home Below this line = LTC or Acute Care
4 Number of Acute Care beds in Ontario Number of Rehab beds in Ontario Number of CCC beds in Ontario Number of LTC beds in Ontario = 77,000 Number of Support Housing / }= 29,000 Assisted Living beds = 75,000 Number of Home beds in Ontario = 13 million
5 Sector Linkage Model : Integration MOHLTC: TCLHIN SHSC/TEGH/SMH TCLHIN Community MD s TCCCAC P R O V I D E N C E CELHIN TSH CELHIN Community MD s CECCAC
6 Sector Linkage Model for Improved Patient Flow AatH initiatives have not demonstrated changes to ER/ALC metrics. The SLM was developed to provide a more focused, effective, sustainable solution that has potential for spread. Based on the healing trajectories of the persons we care for. Three themes: integration, steadystate/sustainability, culture change.
7 Sector Linkage Model for Improved Patient Flow SLM predicated on building capacity in community: highly elastic/costeffective/rapid ramp-up/potential for high levels of customer satisfaction.
8 Sector Linkage Model : Culture Change ALC standard definition adopted provincially. Earlier intervention in acute care. CCAC to designate ALC for LTC destination. Actively pull from acute care to rehab. Aggressive needs-based rehab with focus on sustained independence in home. More case management and navigation in community (family physician, pharmacists).
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10 To reduce the flow in: Avoid Readmissions ( Virtual Ward / Early Discharge Planning / CDM / Case Management) ER Diversion / GEM Nurses Support for Community MD s Primary Care Extended Hours Urgent Care Centres
11 To increase the flow out: Home First / Waiting At Home Increase Community Rehab Capacity CCAC s accountable for D/C Planning Supportive Housing / Assisted Living ALC Long Waiters Strategy ALC within 48 hours strategy
12 Our local health integration network Providence Healthcare The bridge between acute care and home gap gap
13 Once at Providence Healthcare As many as 35 care providers X 2 if you transfer to another unit
14 Gap between our own inpatient and outpatient services gap gap
15 Once home
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18 Providence Healthcare The bridge between acute care and home
19 Philosophy and Supporting Structures Providence Healthcare The bridge between acute care and home
20 Philosophy and Supporting Structures Rehab everywhere, always, one patient at a time Providence Healthcare The bridge between acute care and home
21 The Essential 13 mobility, wound care, safe swallowing, continence, cognition, mental health, nutrition, pain management, home safety, medication management, caregiver support, spiritual support, family physician engagement Philosophy and Supporting Structures Providence Healthcare The bridge between acute care and home
22 Philosophy and Supporting Structures Communication, Collaboration, Coordination Providence Healthcare The bridge between acute care and home
23 Philosophy and Supporting Structures Our environment supports our philosophies, flow and processes Providence Healthcare The bridge between acute care and home
24 Right patient, Right bed, Right time in the patient s journey
25 Information for Our Patients
26 Maximum of 13 care providers
27 Inpatient staff + Outpatient staff = one care team
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29 And our most important downstream partners: TC-CCAC, CE-CCAC, C-CCAC
30 Skin in the game As a pilot project, Providence established an agreement with CE- CCAC (this fiscal year) to provide funds from Providence global budget to top up services above CCAC budgeted service maximums in order to facilitate our discharged patients return to home.
31 Community Health Navigators
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33 How did we pay for all this? Closed 50 beds of 347 beds
34 Results: People served from 1905 to 2040 Balanced budget ALC for LTC from 100 to 30 Percent discharge to home 78% Ave. monthly cost for enhanced service package $1500 Ave FIM at 4 mos. post dc:13 pt. increase
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37 Peter Nord M.D. V.P., C.M.O. and Chief of Staff Providence Healthcare Assistant Prof. U. of T St. Clair Ave. East Toronto, Ontario M1L 1W1
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